Hadzic's Regional Anesthesia > Part XIII. Regional Anesthesia & Acute Pain Management > Chapter 79. Organization of an Acute Pain Management Service Incorporating Regional Anesthesia Techniques Eugene R. Viscusi, MD, Rehana Jan, MD, Leslie Schechter, PharmD, Suzanne Lenart, RNC, Paul H. Willoughby, MD

Continuous Epidural Analgesia

"Use of continuous epidural infusions of local anesthetic with or without opioids has become a cornerstone of multimodal analgesia.⁴⁴ The use of dilute local anesthetic solutions has been shown to decrease the incidence of deep venous thrombosis in the postoperative period.⁴⁵ It is an effective weapon in attenuating the endocrine metabolic response to surgical stress and to provide dynamic pain relief.⁴⁶ The epidural catheter must be functional and cover the dermatomal distribution of the surgical incision to be effective. Epidural catheters are best inserted at the middermatome of surgical trauma. Care must also be taken to advance between 3 and 5 cm of epidural catheter into the epidural space. A shallower insertion results in greater incidence of catheter dislodgement, whereas an excessive length of catheter reduces efficacy and increases risk of catheter knotting. The routinely used nylon epidural catheters are difficult to direct in the epidural space, regardless of the direction of the epidural needle bevel. Hence, it is best to target a short length of catheter at the precise spinal cord level to cover surgical pain.Peripheral neural blockade works best when it is part of a multimodal approach to pain control.⁵⁰ It may offer advantages over continuous catheter-based epidural analgesia in lower limb procedures, particularly when anticoagulation is required for venous thromboembolism (VTE) prophalaxis. For single-injection techniques, adding epinephrine 1:200,000 or clonidine enhances the..."